Review of Claims Submitted for MassHealth by the Office of Dr. Melvin M. Frankel, DMD

This is a Massachusetts State Auditor review of claims that Dr. Melvin M. Frankel, an orthodontic dental provider in Taunton, submitted to MassHealth from July 1, 2005 through June 30, 2010.

“Consequently, in accordance with Chapter 11, Section 12, of the Massachusetts General Laws, the Office of the State Auditor conducted an audit of certain dental claims submitted by Dr. Melvin M. Frankel, DMD during the period July 1, 2005 through June 30, 2010.”

The auditor looked at this provider after an earlier audit found weaknesses in MassHealth’s dental claims system that had allowed ineligible and possibly fraudulent claims to be paid.

“Based on these results, the OSA determined that it was necessary to conduct additional audit work in this area.”

This matters because the audit says MassHealth’s claims system missed improper payments, meaning public healthcare dollars were paid out for claims that violated program rules.

“MassHealth did not detect these unallowable claims because of deficiencies within the Dental Program’s claims processing system.”

For an ordinary taxpayer or MassHealth member, the key point is that the auditor says money should be recovered and billing controls should improve so MassHealth funds are used properly.

“MassHealth should recover the $222,866 that Dr. Frankel was paid for dental radiographs, oral/facial photographic images, orthodontic consultations, and orthodontic retention contrary to state regulations during the audit period.”

The audit found three main problems: payments for services MassHealth rules did not allow, duplicate payments, and payments for some services the records showed were not performed.

“Our audit identified unallowable payments to Dr. Frankel for radiographs, oral facial/photographic images, orthodontic consultations, and orthodontic retention.”

The report recommends that MassHealth recover the improper payments and that Dr. Frankel improve his office procedures so future claims follow the rules and reflect services actually provided.

“In addition, Dr. Frankel should establish procedures to ensure that his office only submits claims to MassHealth for services actually performed for members.”

The report points beyond one provider: it says weak oversight and claims-system edits allowed improper payments to get through, including $222,866 in one category alone.

“Because MassHealth did not adequately monitor DentaQuest’s administration of the Dental Program, it did not identify this system deficiency.”

MassHealth is Massachusetts’ Medicaid program, and DentaQuest was the contractor handling dental claims administration and processing for the Dental Program during this period.

“Under the contract, DentaQuest has both programmatic and administrative responsibilities, including (a) dental provider network administration services, (b) customer services, (c) claims administration and processing, (d) contract administration and reporting, and (e) quality improvement/utilization management.”